Weissleder -- Chest Ddx

Front 1

What is your approach to reading chest x-rays?

Back 1

Out to in:

1) Humeri -- clavicles -- scapulae -- ribs -- spine

2) Pleural margins (look for PTX, nodularity, thickening, mass, or small effusion)


3) Airways


4) Mediastinum

Front 2

What areas of the mediastinum do you have to look at?

Back 2

1) Paratracheal stripe


2) AP window


3) Azygoesophageal recess


4) Paraspinal lines


5) Junction lines

Front 3

What specific structure in the airways must you look at?

Back 3

Posterior wall of bronchus intermedius

Front 4

What is the next thing you look at?

Back 4

Hilar shadows

Front 5

Then?

Back 5

Cardiac silhouette

Front 6

Then?

Back 6

Pulmonary parenchyma

Front 7

What about pulm parenchyma?

Back 7

1) Lung volumes


2) Difference in density between left and right lung


3) Focal or diffuse lung abnormalities

Front 8

What is approach to reading an ICU film?

Back 8

1) Look at position of lines and tubes



2) Look for pneumothorax or pneumomediastinum


3) Look for focal parenchymal opacities


4) Look for diffuse parenchymal opacities

Front 9

What is DDx for focal parenchymal opacities?

Back 9

1) Atelectasis


2) Pneumonia


3) Aspiration


4) Contusion


5) Hemorrhage

Front 10

What is DDx for diffuse opacities in ICU patient?

Back 10

1) Edema


2) Pneumonia


3) ARDS


4) Hemorrhage

Front 11

When encountering an apparently normal CXR, what is the first thing to look at?

Back 11

Bones

Front 12

For what?

Back 12

1) Rib notching


2) Lytic or sclerotic lesions

Front 13

What is the second area to look at?

Back 13

Mediastinum

Front 14

For what?

Back 14

1) Posterior mediastinal mass


2) Subtle hilar mass lesion

Front 15

What next?

Back 15

Airway

Front 16

For what?

Back 16

1) Tracheal mass/stenotic lesion


2) Airway deviation


3) Carinal splaying

Front 17

What is the next area to look at?

Back 17

Lungs

Front 18

For what?

Back 18

1) Retrocardiac disease


2) Hidden nodules


3) Bronchiectasis


4) Subtle interstitial disease


5) Overall differences in lung density


6) Evidence of PE

Front 19

What are signs of right upper lobe collapse?

Back 19

Elevation of minor fissure


Rightward shift of trachea


Elevation of right hilum

Front 20

What does RUL collapse look like when complete?

Back 20

Thickening of right paratracheal stripe

Front 21

What are causes of recurrent right middle lobe atelectasis?

Back 21

Bronchus surrounded by enlarged lymph nodes

Front 22

What is appearance of RLL collapse?

Back 22

Triangular opacity in right retrocardiac region, with obliteration of diaphragm


Opacity over the spine

Front 23

LUL collapse?

Back 23

Difficult to see: Just see hazy density, which can easily be confused with loculated pleural effusion

Front 24

What is a sign seen in LUL collapse?

Back 24

Luftsichel

Front 25

What is luftsichel?

Back 25

On PA view, you see an area of lucency surrounded by increased density, which represents the superior segment of the left lower lobe rising up higher now that the left upper lobe is collapsed.

Front 26

What does the lateral view look like in LUL collapse?

Back 26

The left lower lobe is anterior; thus when it collapses, the minor fissure gets pulled anteriorly with it.

Front 27

What is appearance of LLL collapse?

Back 27

Left retrocardiac opacity


On lat view, posterior displacement of the major fissue

Front 28

What causes lung consolidation?

Back 28

Confluence of acinar shadows

Front 29

What specifically?

Back 29

Fluid, inflammatory exudate, or tissue in acini

Front 30

What types of fluid?

Back 30

Water


Blood


Proteinaceous fluid

Front 31

What causes water in acini?

Back 31

Pulmonary edema

Front 32

What causes blood in acini?

Back 32

Trauma is most common cause

Front 33

What are other causes?

Back 33

Bleeding disorder or anticoag


Pulmonary infarct


Vasculitis, including Goodpastures and Henoch-Schonlein

Front 34

What causes proteinaceous fluid?

Back 34

Alveolar proteinosis

Front 35

What are general causes of inflammatory exudate in acini?

Back 35

Infection and non-infectious inflammation

Front 36

What are noninfectious causes?

Back 36

Allergic hypersensitivity pneumonitis


Chronic eosinophilic pneumonia


BOOP


Loeffler's syndrome


ABPA


Aspiration of lipid material


Sarcoidosis

Front 37

What causes soft tissue in acini?

Back 37

Tumor

Front 38

Which tumors?

Back 38

Bronchioloalveolar CA


Lymphoma

Front 39

What is first step in evaluating solitary pulm nodule?

Back 39

Assess age and smoking status

Front 40

What is the age cutoff?

Back 40

30

Front 41

What if patient is under 30 and non-smoker?

Back 41

Stop or follow up imaging

Front 42

What is the first question to ask if patient is a smoker or is over 30?

Back 42

Are there any prior films

Front 43

What is the question to ask on the prior films?

Back 43

Has the lesion enlarged

Front 44

What if there is no interval change?

Back 44

Assuming this is a good interval, you can do follow-up imaging or stop

Front 45

What if the lesion is enlarging?

Back 45

Biopsy it

Front 46

What if there are no prior films available?

Back 46

Do thin section CT through lesion

Front 47

What are you looking for on thin section CT?

Back 47

Calcification or fat

Front 48

What if there is no calcification or fat?

Back 48

Biopsy it, either percutaneously or via bronch

Front 49

What if there is fat?

Back 49

Presumed hamartoma, and you can stop

Front 50

What if there is calcification?

Back 50

Must assess what type of calcification

Front 51

What types of calcification suggest benign lesion?

Back 51

Diffuse


Popcorn


Concentric (lamellar)


Single central

Front 52

What types of calcification are indeterminate?

Back 52

Stippled


Single eccentric

Front 53

What characteristics of a solitary pulmonary nodule need to be assessed?

Back 53

Shape


Size


Presence of spiculations


Edge (Zone of transition)


Satellite lesions


Cavitation


Doubling time

Front 54

What do satellite lesions suggest?

Back 54

Benignity

Front 55

What does cavitation suggest?

Back 55

Malignancy

Front 56

What doubling time suggests benignity?

Back 56

Less than one month


OR


Greater than 2 years

Front 57

How many criteria are there that can reliably be used to assess a solitary pulmonary nodule as benign?

Back 57

Only 3

Front 58

What are they?

Back 58

1) Presence of fat



2) Benign types of calcificaton



3) No interval growth for 2 years

Front 59

What HU is needed to call lesion calcified?

Back 59

200 HU

Front 60

What percent of the lesion must be calcified before you can even assess the type of calcification?

Back 60

10%

Front 61

What is the exception to the calcification rule?

Back 61

Osteosarcoma and thyroid mets can calcify. However, they will be seen in multiplicity. Only consider this if patient has history of one of these diseases.

Front 62

What are most solitary pulmonary nodules?

Back 62

Granuloma or primary carcinoma

Front 63

What are the rest?

Back 63

Some are AVMs, and the possibility of this should be assessed before biopsy

Front 64

Where are most pulmonary nodules missed?

Back 64

1) Lung apices


2) Central and paramediastinal lungs


3) Superimposed onto ribs and clavicle

Front 65

What is the differential for solitary pulmonary nodule?

Back 65

Tumor


Inflammation


Other

Front 66

What percent are inflammation?

Back 66

53%

Front 67

What types of inflammation?

Back 67

Granuloma from Tb, histo, or coccy

Front 68

What percent are tumor?

Back 68

45%

Front 69

What types of tumor?

Back 69

Primary CA


Solitary met


Hamartoma

Front 70

What percent of solitary lung tumors will be primary CA?

Back 70

70%

Front 71

What percent of solitary lung tumors will be solitary met?

Back 71

10%

Front 72

What percent of solitary lung tumors will be hamartoma?

Back 72

15%

Front 73

What are the other 2% of solitary pulmonary nodules

Back 73

Vascular lesions


Congenital lesions


Miscellaneous lesions

Front 74

What are the vascular lesions that present as nodules?

Back 74

AVM


Pulmonary varix

Front 75

What are the congenital lesions that present as nodules?

Back 75

Sequestration



Bronchial cyst

Front 76

What are the miscellaneous causes of solitary nodule?

Back 76

Round pneumonia


Loculated effusion in fissure (pseudotumor)


Mucous plug


Enlarged subpleural node


Silicosis (rare)

Front 77

What are causes of multiple pulm nodules?

Back 77

Mets


Abscess


Granulomatous lung disease

Front 78

What varieties of granulomatous lung disease cause multiple pulmonary nodules?

Back 78

Infectious and noninfectious

Front 79

What are the infectious causes of granulomatous lung disease?

Back 79

Tb


Fungus

Front 80

What are the noninfectious causes?

Back 80

Sarcoid


Silicosis


Wegener's


Rheumatoid nodules

Front 81

What if the nodules are small, bilateral, and very numerous?

Back 81

Consistent with miliary dz, which has a differential

Front 82

What are the causes of miliary pattern?

Back 82

Tb


Certain mets

Front 83

What are the mets that can do miliary pattern?

Back 83

Thyroid



Melanoma


Breast


Choriocarcinoma

Front 84

What if the nodules are very small?

Back 84

Consistent with nodular interstitial disease

Front 85

What is differential for calcified lung nodules?

Back 85

Depends on average size of nodules.

Front 86

What if nodules are 1 mm or more on average?

Back 86

Tumor


Infection


Silicosis

Front 87

What tumors calcify?

Back 87

Mets

Front 88

Which mets?

Back 88

Thyroid CA


Osteosarcoma


Mucinous carcinomas

Front 89

What are infectious causes of calcified lung nodules?

Back 89

Tb/histo/coccie


Varicella


Schistosomiasis

Front 90

What about calcified nodules that are very small (on average less than 1 mm?)

Back 90

Metastatic calcification, usually from chronic renal disease



Chronic pulmonary venous hypertension



Alveolar microlithiasis

Front 91

What is ddx for a large pulmonary parenchymal mass (>6cm)?

Back 91

Tumor (primary or metastatic)


Abscess


Round atelectasis (associated with effusion)


Intralobar sequestration


Bronchogenic cyst


Hydatid disease

Front 92

What metastatic lesions tend to give big lung mets?

Back 92

SCC from head/neck

Front 93

What is ddx for a large extrapulmonary mass?

Back 93

Loculated pleural effusion


Fibrous tumor of pleura


Chest wall tumors


Mediastinal masses

Front 94

When you have a cystic/cavitary intraparenchymal lesion, what is most helpful (but not always) to determine if benign or malignant?

Back 94

Wall thickness

Front 95

What are criteria?

Back 95

Wall < 2mm thick



Wall 2-15 mm thick


Wall > 15 mm thick

Front 96

What percent of <2mm are benign?

Back 96

95%

Front 97

What percent of 2-15 are benign?

Back 97

50%

Front 98

What percent of >15mm are benign?

Back 98

<5%

Front 99

When the wall is thick, what are you dealing with?

Back 99

cyst

Front 100

What is the differential diagnosis for cyst?

Back 100

1) Pneumatocele


2) Bulla/bleb


3) Cystic bronchiectasis


4) Congenital cysts


5) Hydatid cyst

Front 101

What causes pneumatocele?

Back 101

Infection or trauma

Front 102

What is the difference between a bulla and a bleb?

Back 102

Bulla is intraparenchymal


Bleb is in the pleura

Front 103

What types of congenital cysts are there?

Back 103

1) Bronchogenic cysts


2) Cystic adenomatoid malformation


3) Sequestration can have cystic elements

Front 104

What is the differential diagnosis for a lung cavity (i.e. thick walls)

Back 104

1) Abscess


2) Cavitated tumor


3) Cavitated granulomatous mass


4) Cavitated hematoma

Front 105

What are tumors that can cavitate in the lung?

Back 105

1) SCC (lung or metastatic)



2) Sarcomas



3) TCC of bladder



4) Lymphoma

Front 106

What is true of cavitated granulomatous masses?

Back 106

Usually multiple

Front 107

What are the causes of cavitated granulomatous mass?

Back 107

Tb


Sarcoid


Wegener's


Rheumatoid


Fungus (aspergillus)

Front 108

What entities can have an air crescent sign?

Back 108

1) Invasive aspergillosis


2) Septic emboli


3) Mucor


4) Tb


5) Tumors

Front 109

How do you analyze small cystic disease of the lung?

Back 109

Determine whether the cysts have a true wall or no wall.

Front 110

What is the diagnosis of small cystic disease with no cyst wall?

Back 110

Emphysema

Front 111

What is the differential for small cystic disease with true walls?

Back 111

1) Honeycombing in any end-stage interstitial disease



2) Cystic form of PCP



3) LAM



4) Eosinophilic granuloma

Front 112

What is the approach to interstitial disease? First

Back 112

1) Type of pattern

Front 113

Second?

Back 113

Distribution

Front 114

3rd?

Back 114

Lung volumes

Front 115

4th?

Back 115

Lymph nodes

Front 116

5th?

Back 116

Pleural disease

Front 117

6th?

Back 117

Evolution of disease

Front 118

What is the categorical differential for proximal intraluminal airway mass?

Back 118

Tumor


Inflammatory disease


Foreign body


Mucus plug



Broncholith

Front 119

What percent of upper airway masses are due to tumor?

Back 119

80%

Front 120

What percent of upper airway tumors are benign?

Back 120

25%

Front 121

What is the differential for benign tumors?

Back 121

Hamartoma



Papilloma



Hemangioma



Pleomorphic adenoma

Front 122

What is the differential for malignant tumors?

Back 122

SCC (most common tumor)


Adenoid cystic carcinoma (next most common)


Mucoepidermoid


Carcinoid

Front 123

What percent of upper airway endobronchial tumors are metastatic lesions?

Back 123

5%

Front 124

What tumors tend to invade the trachea from outside?

Back 124

Thyroid


Lung


Esophageal

Front 125

What is clinical scenario that goes with airway mass?

Back 125

Patient undergoing workup for intractable asthma-like symptoms